The Society of Thoracic Surgeons 2008 Cardiac Surgery Risk Models: Part 2-Isolated Valve Surgery
The Society of Thoracic Surgeons 2008 Cardiac Surgery Risk Models: Part 2-Isolated Valve Surgery
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DOI：
10.1016/j.athoracsur.2009.05.056
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发表时间：
2009-07-01
影响因子：
4.6
通讯作者：
Anderson, Richard P.
中科院分区：
文献类型：
--
作者：
O'Brien, Sean M.;Shahian, David M.;Anderson, Richard P.
背景在使用观察数据比较手术技术或提供者时，病例组合的调整至关重要。这通常是通过使用风险模型来实现的，该模型考虑了可能影响结果的术前患者因素。美国胸外科医师协会（STS）使用此类风险模型为STS国家成人心脏手术数据库（NCD）中的参与者创建风险调整后的性能报告。虽然风险模型最初是为冠状动脉搭桥手术开发的，但现在已经开发了类似的模型用于心脏瓣膜手术，特别是随着此类手术的比例增加。最近发表的孤立瓣膜手术的STS模型基于1994年至1997年的数据，不包括接受二尖瓣修复术的患者。STS已经开发了新的瓣膜手术模型，使用当代数据，包括瓣膜修复以及置换。在现有瓣膜模型的基础上，新的STS模型除了死亡率外还包括几种非致命性并发症。使用2002年至2006年的STS数据，针对手术死亡率、永久性卒中、肾衰竭、通气时间延长（> 24小时）、深部胸骨伤口感染、任何原因的再次手术、主要发病率或死亡率复合终点、术后住院时间延长和术后住院时间缩短开发了孤立的瓣膜手术风险模型。研究人群包括接受三种类型瓣膜手术之一的成人患者：单纯主动脉瓣置换术（n = 67，292）、单纯二尖瓣置换术（n = 21，229）或单纯二尖瓣修复术（n = 21，238）。将群体分为60%开发样品和40%验证样品。经过初步的实证研究，三个手术组被合并到一个单一的逻辑回归模型与许多相互作用，使协变量的影响，这些群体之间的差异。根据自动逐步选择和专家小组审查的组合选择变量。所有孤立瓣膜手术的未校正手术死亡率（住院期间，不考虑时间，30天，不考虑地点）为3.4%，未校正住院期间发病率范围从深部胸骨伤口感染的0.3%到长期通气的11.8%。每个模型中的预测因子数量范围从胸骨感染模型中的10个协变量到复合死亡率加发病率模型中的24个协变量。通过c指数测量的区分度范围从再次手术的0.639到死亡率的0.799。当验证样本中的患者根据预测风险的十分位数分为10类时，这些组中观察到的事件与预测事件之间的平均绝对差异范围从深部胸骨伤口感染的0.06%到术后住院时间延长的1.06%。瓣膜手术的新STS风险模型包括二尖瓣修复以及死亡率以外的多个终点。提供了模型系数，并且可以从胸外科医师协会网站公开获得在线风险计算器。
Background. Adjustment for case-mix is essential when using observational data to compare surgical techniques or providers. That is most often accomplished through the use of risk models that account for preoperative patient factors that may impact outcomes. The Society of Thoracic Surgeons (STS) uses such risk models to create risk-adjusted performance reports for participants in the STS National Adult Cardiac Surgery Database (NCD). Although risk models were initially developed for coronary artery bypass surgery, similar models have now been developed for use with heart valve surgery, particularly as the proportion of such procedures has increased. The last published STS model for isolated valve surgery was based on data from 1994 to 1997 and did not include patients undergoing mitral valve repair. STS has developed new valve surgery models using contemporary data that include both valve repair as well as replacement. Expanding upon existing valve models, the new STS models include several nonfatal complications in addition to mortality.Methods. Using STS data from 2002 to 2006, isolated valve surgery risk models were developed for operative mortality, permanent stroke, renal failure, prolonged ventilation (> 24 hours), deep sternal wound infection, reoperation for any reason, a major morbidity or mortality composite endpoint, prolonged postoperative length of stay, and short postoperative length of stay. The study population consisted of adult patients who underwent one of three types of valve surgery: isolated aortic valve replacement (n = 67,292), isolated mitral valve replacement (n = 21,229), or isolated mitral valve repair (n = 21,238). The population was divided into a 60% development sample and a 40% validation sample. After an initial empirical investigation, the three surgery groups were combined into a single logistic regression model with numerous interactions to allow the covariate effects to differ across these groups. Variables were selected based on a combination of automated stepwise selection and expert panel review.Results. Unadjusted operative mortality (in-hospital regardless of timing, and 30-day regardless of venue) for all isolated valve procedures was 3.4%, and unadjusted in-hospital morbidity rates ranged from 0.3% for deep sternal wound infection to 11.8% for prolonged ventilation. The number of predictors in each model ranged from 10 covariates in the sternal infection model to 24 covariates in the composite mortality plus morbidity model. Discrimination as measured by the c-index ranged from 0.639 for reoperation to 0.799 for mortality. When patients in the validation sample were grouped into 10 categories based on deciles of predicted risk, the average absolute difference between observed versus predicted events within these groups ranged from 0.06% for deep sternal wound infection to 1.06% for prolonged postoperative stay.Conclusions. The new STS risk models for valve surgery include mitral valve repair as well as multiple endpoints other than mortality. Model coefficients are provided and an online risk calculator is publicly available from The Society of Thoracic Surgeons website.